High-Energy Pilon Fractures Management: State of the Art

1.0000EOR0010.1302/2058-5241.1.000016 review-article2016

EOR | volume 1 | OCTOBER 2016 DOI: 10.1302/2058-5241.1.000016 Trauma www.efort.org/openreviews

High-energy pilon fractures management: state of the art

Jordi Tomás-Hernández 1% of all lower extremity fractures, and are more common in males between 35 and 40 years of age.1 Such injuries may be caused by high- or low-energy mechanisms. High-energy pilon fractures are challenging injuries. Mul- Axial compression injuries where the talus impacts on tiple options are described for the definitive surgical man- the distal articular surface, causing implosion of the tibial agement of these fractures, but there is no level I evidence plafond are caused by high-energy mechanisms with key for optimal management. The current management and characterisitcs including severe soft-tissue injuries, commi- recommendations for treatment will be reviewed in this nution and multiple displaced articular fragments. article. Conversely, rotational injuries are typically low-energy fractures with less soft-tissue injury and, usually, a distal tibial Anatomical reduction of the fracture, restoration of joint con- spiral fracture pattern. In this review, we will focus on the gruence and reconstruction of the posterior column with a management of high-energy, axial compression injuries. correct limb axis minimising the soft-tissue insult are the key points to a good outcome when treating pilon fractures. Even when these goals are achieved, there is no guarantee Initial management that results will be acceptable in the mid-term due to the The surgical management of pilon fractures is technically frequent progression to post-traumatic arthritis. demanding and requires accurate pre-operative planning. In high-energy fractures with soft-tissue compromise, a The pre-operative plan should include a complete clinical staged treatment is generally accepted as the best way to and radiographic evaluation. It is mandatory to evaluate take care of these devastating fractures and is considered a the neurovascular function and the status of the soft-tis- local ‘damage control’ strategy. sue envelope of the injured extremity, as open wounds, The axial cuts from the CT scan images are essential in lacerations, oedema, deep skin contusions and blisters are order to define the location of the main fracture line, the common findings with pilon fractures (Fig. 1). fracture pattern (sagittal or coronal) and the number of A systematic physical examination should be performed fragments. All of this information is crucial for pre-oper- in order to identify any associated injuries involving the ipsi- ative planning, incision placement and articular surface lateral foot, knee or other locations in cases of polytrauma.2 reduction. In addition, it is useful to identify the patient comorbidities associated with risks of soft-tissue complications such as No single method of fixation is ideal for all pilon fractures, malnutrition, alcoholism, diabetes, neuropathy, tobacco or suitable for all patients. Definitive decision making is use, peripheral vascular disease and osteoporosis.3 Radio- mostly dependent on the fracture pattern, condition of graphic evaluation starts with standard ankle radiographs the soft-tissues, the patient’s profile and surgical expertise. and full-length images of the tibia and fibula in order to Keywords: pilon fracture; high-energy; open reduction determine the displacement of the talus (proximal or and internal fixation; ORIF; distal tibia; tibial plafond; staged medial/lateral dislocation), the proximal extension of the treatment fracture into the shaft, the association of fibular fractures and the metaphyseal comminution. Cite this article: Tomás-Hernández J. High-energy pilon The initial management of this fracture differs depend- fractures management: state of the art. EFORT Open Rev ing on the type of injury. If we are dealing with a low- 2016;1:354-361. DOI: 10.1302/2058-5241.1.000016. energy rotational injury without soft-tissue compromise, it is usually safe to immobilise the extremity in a cast and plan for an early primary open reduction and internal fixa- Introduction tion (ORIF) following the classical principles described in 1979 by Rüedi and Allgöwer.4 On the other hand, early Pilon fractures are distal tibia end fractures affecting the primary ORIF of high-energy pilon fractures is usually weight-bearing articular surface. They represent around associated with soft-tissue complications and, in the case High-energy pilon fractures: state of the art management

Fig. 1 Soft-tissue status after a high-energy pilon fracture. Fig. 2 Spanning external fixation as part of a staged treatment. of an open fracture, the incidence of deep wound infec- spanning situation for a long period due to the initial soft- tion or dehiscence which requires surgical debridement, tissue status (Fig. 2). reported to be necessary in up to 19% of cases.5,6 For that reason, in high-energy fractures with soft- Diagnostics tissue compromise a staged treatment like those described in two 1999 articles7,8 is generally accepted as the best As already mentioned, the most useful method of deter- way to take care of this devastating fracture and is consid- mining the ‘personality’ and morphology of a is the CT ered a local ‘damage control’ strategy.9 The protocol con- scan after spanning the fracture. The axial cuts from the sists of initial ankle-spanning external fixation (delta or CT scan are mandatory images in order to define the loca- rectangular frame) with or without fibular fixation and tion of the main fracture line, the fracture pattern (sagittal delayed definitive ORIF until soft-tissues are restored. The or coronal) and the number of fragments12 (Fig. 3). timing of fibular fixation is controversial10 as an acute All of this information is crucial for pre-operative plan- inappropriate incision placement for fibular fixation can ning, incision placement and articular reduction. CT has compromise future approaches. We rarely fix the fibula at been shown to provide additional beneficial information the same time as we perform the spanning external fixa- for 82% of cases, resulting in a change to the surgical plan tion, because we plan the definitive surgical approaches in 64% of cases operations.13 after viewing the CT scan images post-external stabilisa- Topliss, Jackson and Atkins12 used the CT scan on 126 tion. This facilitates the fracture interpretation under trac- consecutive pilon fractures. Their study offered a CT- tion.11 Temporary stabilisation should be performed as based classification of fracture pattern variability. They soon as possible with the goal of restoring the alignment classified fracture patterns as either ‘sagittal’ or ‘coronal’, rather than obtaining a perfect reduction, while bearing in based on the main fracture line from the axial CT cuts at mind the need to avoid pins crossing possible future sur- the plafond level. They correlated this information with gical fields. An extension of the fixator onto the first meta- patient and deformity characteristics, finding that sagittal tarsal is helpful to avoid an equinus contracture in cases patterns were more frequently related to high-energy where it is expected to be necessary to mantain the injuries in young patients and tended to present with

355 Fig. 3 Fracture patterns: coronal, saggital and both. varus deformity, while coronal patterns tended to be and its usage has gradually gained traction, becoming related to low-energy fractures in elderly patients and more used and accepted. often presented with valgus deformity. Fracture pattern will be different depending on the position of the foot and the force direction of the impact. Definitive management If the foot is dorsiflexed, the anterior part of the pilon will Controversy still exists regarding how best to treat these be more comminuted, while if the foot is neutral or plan- injuries, but most clinicians advocate surgical interven- tar flexed, the central and posterior part will be more tion, unless contraindicated, with some combination of affected respectively. Usually there are three constant ORIF or external fixation with or without limited ORIF. articular fragments that can vary in size and comminution: Treatment goals include anatomical reduction of the anterolateral, posterolateral and medial. From a surgical articular surface, restoration of the extremity length, rota- point of view, it is helpful to divide the distal tibia and tion and axial alignment with respect to the soft-tissue plafond into three basic columns: lateral, medial and pos- envelope with a stable construct that allows early motion terior.14 Generally, posterior fragments are less commi- of the ankle to achieve a stable, reduced and healed ankle nuted than those in the anterior or central areas. which will allow ambulation. Multiple options are described for the definitive surgical management of pilon Classifications fractures, but there is no level I evidence for optimal management.17 Actual treatments are described below. The most used radiograph classifications for pilon frac- 4 tures are those of Rüedi and Allgöwer, and the AO Foun- Open reduction internal fixation (ORIF) dation and Orthopaedic Trauma Association classifications (AO/OTA).15 Once the soft-tissues have recovered from injury and the Rüedi and Allgöwer classified pilon fractures into three ‘personality’ of the fracture has been assessed from CT groups: scans, it is time to plan the surgical technique. The ten- dency is to design the approach closer to the main frac- Type I: Non-displaced fractures; ture line in the axial cuts of the CT scan, to minimise the Type II: Displaced fractures with loss of articular con- soft-tissue damage and surgical stripping. gruency; The restoration of the articular surface normally starts Type III: Displaced and severely comminuted fractures by opening the more anterior articular fragments to visu- with impaction. alise the central and posterior fragments (Fig. 4). The individual articular fragments are then reduced The AO/OTA classification divided pilon fractures into from posterior to anterior, using the posterolateral articu- three main groups — 43-A: extra-articular fractures; 43-B: lar fragment as a template. The provisional reduction of partial articular fractures; 43-C: complete articular each fragment should be performed with Kirschner (K-) fractures. wires, and definitive fixation can be accomplished with The Rüedi and Allgöwer classification has been widely two or three screws. Sometimes there are smaller osteo- used over the years, but has low inter-rater reliability, chondral fragments that can be fixed with mini-fragment especially between types II and III. The AO/OTA classifica- screws, bioresorbable pins, or even flush-cut and buried tion was proven to have superior inter-rater agreement,16 wires.18 When the articular reduction is achieved, multiple

356 High-energy pilon fractures: state of the art management

Fig. 4 Opening the more anterior fragments allows access to Fig. 5 Pilon fracture treated with a minimally invasive, the central and posterior comminution. percutaneous medial technique. anatomical low profile locking or non-locking plates are acting as a buttress plate. This approach must be used available to connect the articular fragment to the tibia.19 with caution because of its possible skin complications.27 Generally, fracture patterns that end with valgus failure After posterior reduction is achieved, the posterior col- and lateral compression (coronal patterns) have main umn acts as a template to reduce the anterior pilon. An fracture lines that exit laterally in the tibia, and are better advantage of the posterolateral approach is that the fibula supported with anterolateral plating techniques through can be addressed if needed from the same incision by anterolateral approaches. On the other hand, fracture pat- mobilising the peroneal tendons medially (Fig. 7).28 terns that end with varus angulation of the tibia with lat- Controversy remains regarding when and how to per- eral tension failure and compression of the medial side form the fibular fixation that is associated with pilon frac- (sagittal patterns) are better supported with medial but- tures in 90% of cases.29 Classically, the surgical sequence tress plates; most of them can be managed with good described by Rüedi and Allgöwer begins with the fibular outcomes through minimally invasive techniques with reduction.4 The benefits of beginning by fixing the fibula percutaneous medial approaches (Fig. 5).20-22 include the restoration of the length of the lateral column More complex fractures with complete articular injuries and the indirect reduction by ligamentotaxis that can be in the medial, lateral and central areas usually need mid- achieved of the anterolateral Chaput fragment, and the line, anteromedial or anterior extensile approaches23,24 posterolateral Volkman fragments that remain in continu- that allow visualisation of the entire plafond to reduce the ity with the lateral malleolus.30 However there are some joint. These complex fractures may require a combination concerns about fixing the fibula as the first surgical step: of anterolateral and medial plates for their fixation (Fig. 6).25 In the majority of pilon fracture cases, posterior frag- •• In cases of severe fibular comminution, it can be diffi- ments can be addressed directly or indirectly from ante- cult to obtain a perfect anatomical reduction in terms rior approaches, but there are some situations where the of length and rotation. The lack of anatomical reduc- posterior fracture aspect is better approached directly tion of the fibula may prevent anatomical reduction of from a posterolateral approach, in the interval between the tibia. In that situation, it can be more helpful to the peroneal tendons and the flexor hallucis longus,26 start the surgical sequence by reducing the tibia. such as pilon fractures with extensive comminution of the •• In those cases where an anterolateral tibial approach is metaphyseal—diaphyseal aspect of the posterior column planned, the addition of a close incision for the fibula with shortening and malalignment, or cases where there may contribute to wound complications and it is not are incarcerated fragments posteriorly that are not acces- recommended. If we combine approaches, we have to sible from the anterior. In those scenarios, the posterior bear in mind the need to leave a skin bridge of at least column must be reduced and then fixed with a one-third 6 cm between them, in order to avoid such complica- tubular plate or a pre-contoured anatomical implant tions.31 In such a scenario, the stabilisation of the

357 Fig. 6 Complex fractures may require a combination of different plates and approaches for fixation.

Fig. 7 An advantage of the posterolateral approach is that the fibula can be addressed if needed from the same incision, by mobilising the peroneal tendons medially.

fibular fracture with a rod or titanium elastic nail may such as a 3.5 mm reconstruction plate or a low-contact be an alternative, although Lee et al32 found a lower dynamic compression plate acting as a bridge plate. rate of malunion and ankle arthrosis when the fibula Generally, the post-operative protocol following ORIF was fixed by plating. includes a posterior splint for two weeks to prevent ankle •• In complex C3-type fractures with bone loss and com- equinus and to allow for soft-tissue healing, followed by a minution in the metaphyseal area, ignoring the fibula removable boot and non-weight-bearing for ten to 12 fracture allows the option of tibial shortening to weeks. Free ankle range of motion exercises are permitted improve bone contact and management of the bone once the skin has healed. At ten to 12 weeks post-opera- defect. tively, progressive weight-bearing is allowed, depending on radiograph results. A one-third tubular plate is usually chosen when ana- External fixation with or without limited ORIF tomical reduction can be achieved in fracture patterns with minimal comminution. However, in the presence of As a result of the unacceptable complication rates classi- severe comminution a more rigid implant is preferred cally linked to early ORIF of pilon fractures in the 1980s,6

358 High-energy pilon fractures: state of the art management

simple as a partial ring with two tensioned wires for the epiphyseal region connected to a single rod attached to two diaphyseal Schanz screws. Experienced surgeons now recommend at least two or three pins proximal to the fracture, inserted from different directions with a cross-braced frame, and at least two or three tensioned 2 mm wires in the articular portion. To reduce the risk of joint infection, intra-articular placement of the wires is to be avoided, if possible. Pins that are inserted less than 20 mm proximal to the tibiotalar joint may enter the joint capsule (Fig. 8). Several authors (Leung et al35 and Bone et al,36 for example) have reported results using external fixation with limited ORIF that are comparable with previous studies using ORIF alone. A recent meta-analysis by Wang et al37, reaches the same conclusion. Nine studies investi- gating ORIF and limited internal fixation combined with an external fixator (LIFEF) for the treatment of tibial plafond fractures were included in this meta-analysis. The purpose of the analysis was to determine whether LIFEF yielded fewer post-operative complications when compared with ORIF. The meta-analysis found that rates of nonunion, malunion and delayed union, bone healing, deep and superficial infection, arthritis symptoms and chronic osteomyelitis were comparable between groups. There is not a single method of fixation ideal for all Fig. 8 Hybrid external fixator. pilon fractures or suitable for all patients. Definitive decision-making is mostly dependent on the fracture pattern, the condition of the soft-tissues, the patient’s profile and alternative management strategies were developed. Exter- surgical expertise. nal fixation was a rational strategy to minimise wound complications and deep infections in selected cases, but Outcomes C-type fractures with impacted fragments are difficult to reduce by ligamentotaxis alone. The articular incongru- Outcomes following high-energy pilon fractures are usu- ence and malunion in those cases led to a compromised ally poor when compared with functional outcome scores outcome due to the development of early post-traumatic of the uninjured population. Pollak et al38 studied the mid- arthritis.33 In order to improve the articular reduction that term outcomes of pilon fractures managed with either can be obtained with external fixation, it is useful in many ORIF or external fixation, with or without limited ORIF. cases to perform a limited articular ORIF as an adjunct.34,35 Patient scores in the SF-36 General Health Questionnaire Generally, fractures with metaphyseal comminution and were significantly lower than age-matched controls. They large articular fragments reducible by ligamentotaxis, demonstrated that 43% of previously working patients open fractures with soft-tissue injury that compromises were unemployed after suffering the injury and 68% of standard approaches and severely contaminated open individuals attributed their situation to sequelae of their fractures or patients with comorbidities are scenarios fractures. Sands et al39 reported similar outcomes using where treatment with an external fixation with or without the same SF-36 score. Another very important finding is limited ORIF can be a good option. that clinical results usually deteriorate with time, and the Hybrid external fixators are attached to the distal tibial incidence of post-traumatic arthritis significantly increases epiphysis through a partial ring with tensioned wires. over time.40 Proximally, the hybrid fixator is constructed from con- ventional external fixator components attached to the Conclusions diaphysis with Schanz screws. The proximal frame attaches to the distal ring with appropriate connecting Anatomical reduction of the fracture, restoration of joint clamps. A variety of frame configurations have been pro- congruency and reconstruction of the posterior column posed. Early hybrid fixators for the distal tibia were as with a correct limb axis and thus minimising soft-tissue

359 insult are the key factors of a positive outcome when treat- 5. White TO, Guy P, Cooke CJ, et al. The results of early primary open reduction and ing pilon fractures. Even when these goals are achieved, internal fixation for treatment of OTA 43.C-type tibial pilon fractures: a cohort study. J Orthop there is no guarantee that results will be acceptable in the Trauma 2010;24:757-763. mid-term due to the frequent progression to post-trau- 6. mcFerran MA, Smith SW, Boulas HJ, Schwartz HS. Complications encountered 40 matic arthritis. No method of treatment has shown clear in the treatment of pilon fractures. J Orthop Trauma 1992;6:195-200. superiority regarding rates of nonunion, malunion, 7. sirkin M, Sanders R, DiPasquale T, Herscovici D Jr. A staged protocol for soft delayed union, bone healing, deep and superficial infec- tissue management in the treatment of complex pilon fractures. J Orthop Trauma 1999;13:78-84. tion, arthritis symptoms or chronic osteomyelitis, there- fore we can conclude (as Sirkin and Sanders41 proposed) 8. Patterson MJ, Cole JD. Two-staged delayed open reduction and internal fixation of that surgeons should treat these complex fractures with severe pilon fractures. J Orthop Trauma 1999;13:85-91. the method with which they are most comfortable. Sur- 9. Blauth M, Bastian L, Krettek C, Knop C, Evans S. Surgical options for the geons who feel comfortable with techniques of internal treatment of severe tibial pilon fractures: a study of three techniques. J Orthop Trauma fixation are best qualified to perform open reductions, 2001;15:153-160. while surgeons who have experience with percutaneous 10. Williams TM, Marsh JL, Nepola JV, et al. External fixation of tibial plafond fixation and hybrid external fixator application should use fractures: is routine plating of the fibula necessary? J Orthop Trauma 1998;12:16-20. this method. 11. teixidor-Serra J, Alvarez-Ferre S, Tomás-Hernández J, et al. Tibial plafond fractures: retrospective review. J Bone Joint Surg [Br] 2011;93-B(suppl II):217. Author information 12. topliss CJ, Jackson M, Atkins RM. Anatomy of pilon fractures of the distal tibia. Department of Orthopaedic and Trauma Surgery, Hospital Vall d’Hebron, J Bone Joint Surg [Br] 2005;87-B:692-697. Barcelona, Spain 13. tornetta P III, Gorup J. Axial computed tomography of pilon fractures. Clin Orthop Correspondence should be sent to: Jordi Tomás-Hernández, Department of Relat Res 1996;323:273-276. Orthopaedic and Trauma Surgery, Hospital Vall d’Hebron, Universitat Autonoma 14. Cole PA, Mehrle RK, Bhandari M, Zlowodzki M. The pilon map: fracture lines and de Barcelona (UAB), Passeig Vall d’Hebron, 119-129 08035 Barcelona, Spain. comminution zones in OTA/AO type 43C3 pilon fractures. J Orthop Trauma 2013;27:e152-e156. Email: [email protected] 15. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes Conflict of Interest committee. J Orthop Trauma 2007;21(suppl):S1-S133. None declared. 16. swiontkowski MF, Sands AK, Agel J, et al. Interobserver variation in the AO/ OTA fracture classification system for pilon fractures: is there a problem? J Orthop Trauma 1997;11:467-470. Funding No benefits in any form have been received or will be received from a commercial 17. Calori GM, Tagliabue L, Mazza E, et al. Tibial pilon fractures: which method of party related directly or indirectly to the subject of this article. treatment? Injury 2010;41:1183-1190. 18. tarkin IS, Clare MP, Marcantonio A, Pape HC. An update on the management Licence of high-energy pilon fractures. Injury 2008;39:142-154. ©2016 The author(s) 19. stapleton JJ, Zgonis T. Surgical treatment of tibial plafond fractures. Clin Podiatr This article is distributed under the terms of the Creative Commons Attribution- Med Surg 2014;31:547-564. NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) 20. Borens O, Kloen P, Richmond J, et al. Minimally invasive treatment of pilon which permits non-commercial use, reproduction and distribution of the work with- fractures with a low profile plate: preliminary results in 17 cases. Arch Orthop Trauma Surg out further permission provided the original work is attributed. 2009;129:649-659. 21. Borg T, Larsson S, Lindsjö U. Percutaneous plating of distal tibial fractures. References Preliminary results in 21 patients. Injury 2004;35:608-614. 1. mandi DM, Belin RP, Banks J, Barrett B. Pilon fractures. Clin Podiatr Med Surg 22. Collinge C, Kuper M, Larson K, Protzman R. Minimally invasive plating of 2012;29:243-278, viii. high-energy metaphyseal distal tibia fractures. J Orthop Trauma 2007;21:355-361. 2. Crist BD, Khazzam M, Murtha YM, Della Rocca GJ. Pilon fractures: advances in 23. Assal M, Ray A, Stern R. Strategies for surgical approaches in open reduction surgical management. J Am Acad Orthop Surg 2011;19:612-622. internal fixation of pilon fractures. J Orthop Trauma 2015;29:69-79. 3. Teeny SM, Wiss DA. Open reduction and internal fixation of tibial plafond 24. Assal M, Ray A, Stern R. The extensile approach for the operative treatment of fractures. Variables contributing to poor results and complications. Clin Orthop Relat Res high-energy pilon fractures: surgical technique and soft-tissue healing. J Orthop Trauma 1993;292:108-117. 2007;21:198-206. 4. rüedi TP, Allgöwer M. The operative treatment of intra-articular fractures of the 25. Jacob N, Amin A, Giotakis N, et al. Management of high-energy tibial pilon lower end of the tibia. Clin Orthop Relat Res 1979;138:105-110. fractures. Strategies Trauma Limb Reconstr 2015;10:137-147.

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26. Konrath GA, Hopkins G II. Posterolateral approach for tibial pilon fractures: a 34. Papadokostakis G, Kontakis G, Giannoudis P, Hadjipavlou A. External report of two cases. J Orthop Trauma 1999;13:586-589. fixation devices in the treatment of fractures of the tibial plafond: a systematic review of the 27. Bhattacharyya T, Crichlow R, Gobezie R, Kim E, Vrahas MS. Complications literature. J Bone Joint Surg [Br] 2008;90-B:1-6. associated with the posterolateral approach for pilon fractures. J Orthop Trauma 2006;20:104-107. 35. leung F, Kwok HY, Pun TS, Chow SP. Limited open reduction and Ilizarov 28. Ketz J, Sanders R. Staged posterior tibial plating for the treatment of Orthopaedic external fixation in the treatment of distal tibial fractures. Injury 2004;35:278-283. Trauma Association 43C2 and 43C3 tibial pilon fractures. J Orthop Trauma 2012;26:341-347. 36. Bone L, Stegemann P, McNamara K, Seibel R. External fixation of severely 29. Barei DP, Nork SE, Bellabarba C, Sangeorzan BJ. Is the absence of an comminuted and open tibial pilon fractures. Clin Orthop Relat Res 1993;292:101-107. ipsilateral fibular fracture predictive of increased radiographic tibial pilon fracture severity? 37. Wang D, Xiang J-P, Chen X-H, Zhu Q-T. A meta-analysis for postoperative J Orthop Trauma 2006;20:6-10. complications in tibial plafond fracture: open reduction and internal fixation versus limited 30. rouhani A, Elmi A, Akbari Aghdam H, et al. The role of fibular fixation in the internal fixation combined with external fixator. J Foot Ankle Surg 2015;54:646-651. treatment of tibia diaphysis distal third fractures. Orthop Traumatol Surg Res 2012;98:868-872. 38. Pollak AN, McCarthy ML, Bess RS, Agel J, Swiontkowski MF. Outcomes 31. howard JL, Agel J, Barei DP, Benirschke SK, Nork SE. A prospective study after treatment of high-energy tibial plafond fractures. J Bone Joint Surg [Am] 2003;85- evaluating incision placement and wound healing for tibial plafond fractures. J Orthop A:1893-1900. Trauma 2008;22:299-305. 39. sands A, Grujic L, Byck DC, et al. Clinical and functional outcomes of internal 32. lee Y-S, Chen S-W, Chen S-H, et al. Stabilisation of the fractured fibula plays fixation of displaced pilon fractures. Clin Orthop Relat Res 1998;347:131-137. an important role in the treatment of pilon fractures: a retrospective comparison of fibular 40. Chen SH, Wu PH, Lee YS. Long-term results of pilon fractures. Arch Orthop Trauma fixation methods.Int Orthop 2009;33:695-699. Surg 2007;127:55-60. 33. Borrelli J Jr, Ricci WM. Acute effects of cartilage impact. Clin Orthop Relat Res 41. sirkin M, Sanders R. The treatment of pilon fractures. Orthop Clin North Am 2004;423:33-39. 2001;32:91-102.

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